Volunteer Application

Office Use Only
Rcvd Date: ______________ O/T Date: ______________ UAttend#: ______________
Ride Year: _______________
Volunteer Application
Name: ___________________________________________
E-Mail: _________________________________________________
Address: _____________________________________________
City: __________________________
Zip: ______________
Home/Cell #: _________________________________ Cell provider: _________________________Text Msg? Yes [ ]
Would you like reminder notifications for classes, clinics, etc via email or text? Circle your preference: Email
Birthday: ____________________________
Veteran? Yes [ ]
Text
No [ ]
Both
Matching Fund Program*? Yes [ ]
*Many places of employment, credit unions, etc., offer matching fund programs where your donations of money or volunteer hours to designated charities will be matched by
the employer, credit union, etc. This is particularly helpful during Ride-A-Thon and other fund raising events.
Place of Employment: _________________________________________ Type of Work: _________________________________
Is this for school/internship/community service hours? Y/N
School Name:
Class Name:
Volunteer Availability
(All times are flexible)
Please Circle:
M = Morning 7-11am MD = Mid-Day 11-4pm E=Evening 3-8pm
Mon (M MD E)
Tue (M MD E)
Fri (M MD E)
Wed (M MD E)
Sat (M MD E)
Thur (M MD E)
Sun (M MD E)
Volunteer Jobs
Volunteering is a tremendously self-rewarding adventure. At Horses Help, you can choose from a great many jobs and
committees. All of these are designed to help support our special needs programs. Whatever your talents or interests,
we can put them to good use at Horses Help! Please check the box for the jobs that interest you.
ADMINISTRATIVE & MARKETING
YES [ ]
HORTICULTURE & FACILITY MAINTENANCE:
YES [ ]
Data entry, drafting correspondence, meeting notes, phoning,
Are you a handyman or green thumb type? We can always use
research, accounting, create newsletters, maintain our website,
help to maintain and improve the premises. Weed, water and pick
create story boards, take pictures and reach out to others to share anything that’s ripe! Come out and cultivate our fruit and veggie
your passion.
producing garden and train future horticulture volunteers.
FUNDRAISING:
YES [ ]
The Hunter & Gatherers reach out to local businesses to donate
goods and products for raffles and auctions throughout the year.
The Cardinals Crew runs two vending locations within the
University of Phoenix Stadium during all home games. Both these
teams help keep our riders in the saddle.
VOLUNTEER SUPPORT
YES [ ]
Attend volunteer fairs at local schools and companies to promote
the various volunteer opportunities available to our community.
Help develop and assist with orientations and training throughout
the year as well as with the planning our annual volunteer
appreciation day and monthly birthday acknowledgments.
SPECIAL EVENTS:
YES [ ]
Attend local equine events to promote Horses Help, visit a nursing
home or school with our miniature horse; spend time planning a
golf tournament, dinner and auction or any other of our amazing
events!
TACKS FIFTH AVENUE:
YES [ ]
Help coordinate used tack and saddle drives within the equine
community and at small shows around the valley. Assist with the
organization of tack within the store and help execute monthly
store openings and sales.
SIDEWALKER:
YES [ ]
Many of our riders may need assistance in maintaining their
balance or in processing instructor directions. While students
learn how to ride, side walkers provide physical, emotional and
verbal support while walking next to the horse.
BARN BUDDY (no horse experience needed):
YES [ ]
Looking to roll up your sleeves and get a little dirty?? Well look no
further! Barn buddies help with stall cleaning, feeding, turn out,
etc. No horse experience required, however you must be able to
work independently alongside our other barn buddies.
FREEDOM RIDERS:
YES [ ]
Are you ready to share your pride in our veterans? We have a
specially designed program to serve our veterans or the families
of those who serve.
HORSE LEADER (horse experience required):
YES [ ]
Riders who need assistance in steering their horses during class
need assistance from you! Come before class to groom, warm-up
and tack horses and then lead them for our students.
Volunteer Application, May 7, 2015
Page 1
Volunteer Information
T-Shirt Size:
S
M
L
XL XXL
Are you under the age of 18? If yes, it is imperative, before you start volunteering, to have a parent or guardian sign the:
1) Photo Release, 2) Liability Release, and 3) Emergency Medical Treatment Consent
How did you hear about Horses Help?_________________________________________________________________________
This information is important for Horses Help to study the most effective means of reaching the public through the media.
Horse Experience: Please briefly describe your experience with horses, if any, below
All our volunteers ‘donate’ on an annual basis by giving their time. However, we also ask all first time
volunteers to make a monetary donation of $10 to cover administrative and training costs.
Yes [ ]
Have you had an immunization against Tetanus in the past 10 years? If yes, when? __________
Yes [ ]
Have you had CPR/First Aid Training? If yes, when? __________
Yes [ ]
Would you be interested in taking a special group class for CPR?
Yes [ ]
Do you speak a language other than English? If YES, which language(s)?
______________________________________________________________________________________
Yes [ ]
Do you know American Sign Language?
Yes [ ]
Have you worked with people with disabilities before? If yes, please explain:
Yes [ ]
Time Commitment
Horses Help is a volunteer dependent non-profit organization. Do you understand that if you do not come at your
designated volunteer time, a rider may not be allowed to ride due to safety precautions?
Yes [ ]
Can you commit to helping for at least a 6-week period?
Yes [ ]
Can you commit to 3-4 hours per week, mid-September through May?
Yes [ ]
Would you be willing to be listed on an ‘On Call’ list? In the event that a class is short volunteers may we call you as a
substitute?
Yes [ ]
If you answered YES to the above, and you were called for an emergency substitution, how quickly could you get
to Horses Help?___________
Physical Commitment
Can you walk briskly for 30 minutes beside a horse?
Yes [ ]
Are you comfortable jogging beside a horse for a short distance?
Yes [ ]
Given a chance to change sides, can you hold one of your arms above your shoulder and support modest weight?
Yes [ ]
Do you have any physical limitations or medical conditions about which we should know?
Yes [ ]
Volunteer Application, May 7, 2015
Page 2
Donation Information
All our volunteers ‘donate’ on an annual basis by giving their time. However, we also ask all first time volunteers
to make a monetary donation of $10 to cover administrative and training costs. You will also receive a volunteer
decal with your donation.
NAME AS I WOULD LIKE LISTED IN PUBLICATIONS: ________________________________________________
Please do not list my name in any publications
Address:______________________________________________________________________________________
City: ____________________________________ State: ___________ Zip: _____________
Email Address:________________________________________________ Phone: __________________________
ANY gift can help a horse or human!!!
I would like to contribute $___________________today.
PLEASE ACCEPT A MONTHLY GIFT OF:
_____$5.00 MONTHLY FOR ONE YEAR
_____$10.00 MONTHLY FOR ONE YEAR
_____$25.00 MONTHLY FOR ONE YEAR
_____$50.00 MONTHLY FOR ONE YEAR
_____$100.00 MONTHLY FOR ONE YEAR
_____$200.00 MONTHLY FOR ONE YEAR
_____MY CHECK IS ATTACHED, MADE PAYABLE TO HORSES HELP THERAPEUTIC RIDING CENTER
_____Please charge $________________to my: American Express
Discover
MasterCard
Visa
Card #________________________________________________-Exp. Date_________________ CCV # __________
Name as it appears on card: ________________________________________________________________________
Billing address (if different from above): ______________________________________________________________
_________________________________________________________________________________________________
Signature: ________________________________________________ Date: _________________________________
_____I/We authorize Horses Help to charge the above credit card for my pledge each month/year.
NAME (Please Print): _____________________________________
PHONE NUMBER: _______________________________________
Volunteer Application, May 7, 2015
Page 3
Liability Release
I understand that horses are unpredictable and even the most docile animal can and may step on, bite, push
off balance, stumble, throw, or otherwise injure any person working with or around it. I will exercise safety
precautions for my own protection, and I agree to abide by the policies and procedures of Horses Help, as
such policies may be amended from time to time. I also agree to exercise proper care and conduct at all times
while on or near any horse.
Neither Horses Help, nor any of its officers, instructors, volunteers, participants, employees, agents or owners
of the property where Horses Help events are conducted shall be held liable for any claims, demands, injuries,
or damages, arising out of or in connection with my participation in any Horses Help event.
I further acknowledge that I will not hold Horses Help, its officers, instructors, volunteers, participants,
employees, agents or owners of the property where Horses Help events are conducted, liable or responsible
for any injury sustained by me while participating in activities at sites where horse therapy classes and related
events may be held. I ride and/or participate at my own risk, and agree to take all necessary precautions to
prevent any and all accidents. These precautions include, but are not limited to, the wearing of protective
headgear.
I hereby release Horses Help, its officers, instructors, volunteers, participants, employees, agents as well as
the owner of the property, where lessons, horse shows or other Horses Help events occur, from all liability for
property damage and personal injury to me, and I assume the risk of injury which I may sustain arising from
approaching, handling, or riding a horse in connection with Horses Help activities.
This agreement shall apply to any horse or horses being used or maintained upon the grounds where a Horses
Help event is being held, or any person or equipment affiliated with said event.
Furthermore, I assume full responsibility and liability for the conduct and safety of any and all persons I bring
onto the property where Horses Help events are conducted, including minors.
VOLUNTEERS: I represent that I am physically able to undertake all reasonable volunteer activities
and I participate in such activities at my own risk.
INITIALS: __________
Warning: Under Arizona Law, an equine activity sponsor or equine professional is not liable for any injury to or the death of a
participant in equine activities resulting from the inherent risks of equine activities, pursuant to A. R. S. s 12-553.
I have read and understand all of the above and waive any claim which may arise against Horses Help, its
officers, instructors, volunteers, participants, employees, agents or owners of the property where Horses Help
events are conducted.
This agreement is effective upon signing and continues so long as I participate in Horses Help events.
I agree to pay all costs and attorneys’ fees arising from any suit, legal proceedings or threatened proceedings
that are or may be brought by me contrary to the terms of this Agreement.
____________________________________________________
_________________
Signature of Volunteer
(If volunteer is under the age of 18, Parent/Guardian must sign)
Date
Volunteer Application, May 7, 2015
Page 4
Photo/Video Release
I understand that I consent to and authorize the use and reproduction of any and all photographs and any
other audiovisual materials taken of me, my son/daughter or ward, for promotional printed material,
educational activities, social media and exhibitions or for any use for the benefit of Horses Help.
I Consent
I Do Not Consent
____________________________________________________
_________________
Signature of Volunteer
(If volunteer is under the age of 18, Parent/Guardian must sign)
Date
Risk Management Statements
 I understand that I cannot smoke while on the property of Horses Help unless in
designated area.
Y
N
 I understand Horses Help has designated business hours at which time staff
are present on property.
Y
N
 I understand that I must wear an approved ASTM approved riding helmet to ride
any horse.
Y
N
 I understand that horses are not to be fed anything by hand. Hand feeding
encourages biting and nipping.
Y
N
 I understand that horses are unpredictable. They may kick, bite, and step on me.
Y
N
____________________________________________________
_________________
Signature of Volunteer
(If volunteer is under the age of 18, Parent/Guardian must sign)
Date
Confidentiality Statement
 Volunteers, riders and their families have a right to privacy that gives them control over the dissemination
of their medical and/or other sensitive information. Horses Help shall preserve that right of confidentiality
for all individuals in its program.
I, by signing below, acknowledge this policy and will abide by it.
____________________________________________________
_________________
Signature of Volunteer
(If volunteer is under the age of 18, Parent/Guardian must sign)
Date
Volunteer Application, May 7, 2015
Page 5
Authorization for Emergency Medical Treatment
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or
while being on the property of the agency, I authorize HORSES HELP to:
1. Secure and retain medical treatment and transportation if needed.
2. Release participant records upon request to the authorized individual or agency involved in the medical emergency
treatment.
Applicant Name: __________________________________________________________ Date of Birth: _______________________
Address: ___________________________________________________________________________________________________
City/State/Zip: _______________________________________________________________________________________________
Cell Phone: ____________________________________________________
Receive Text?
Y
/
N
In the event that I cannot be reached, please contact:
1.
Name:_______________________________ Phone: ___________________________ Relationship: ______________________
2.
Name:_______________________________ Phone: ___________________________ Relationship: ______________________
Physician’s Name: ____________________________________________ Phone: ________________________________________
Health Insurance Co.: _________________________________________ Insurance ID: ____________________________________
Preferred Medical Facility: _____________________________________________________________________________________
Allergies: ___________________________________________________________________________________________________
Current Medications: __________________________________________________________________________________________
Consent Plan
This authorization includes x-ray, surgery, hospitalization, medication and any procedure deemed “life saving” by the physician. This
provision will only be invoked if the person listed below in unable to be reached.
Consent Signature: _____________________________________________________ Date: _________________________
(If volunteer is under the age of 18, Parent/Guardian must sign)
Emergency Contact Name: ______________________________________________ Phone: ________________________
Address: _____________________________________________ City/State/Zip: __________________________________
Non Consent Plan
I do not give my permission for emergency medical treatment/aid in the case of illness or injury during the process of receiving services
or while being on the property of the Agency. In the event emergency treatment/aid is required, I wish the following procedures to take
place:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Non-Consent Signature: __________________________________________________ Date: _________________________
(If volunteer is under the age of 18, Parent/Guardian must sign
Volunteer Application, May 7, 2015
Page 6